Provider Demographics
NPI:1629001714
Name:MOYER, DONNA R (DO)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:R
Last Name:MOYER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 32627
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48232-0627
Mailing Address - Country:US
Mailing Address - Phone:866-744-1452
Mailing Address - Fax:586-412-4101
Practice Address - Street 1:1375 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1350
Practice Address - Country:US
Practice Address - Phone:810-667-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010106382085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICA3518OtherMEDICARE RR GROUP PIN
MI300111755OtherRRMC
MI310D460020OtherBCBS GROUP PIN
MI4095728Medicaid
MI4095728Medicaid
MI300111755OtherRRMC
MI0F36125024Medicare PIN
F42104Medicare UPIN
MI0F36125Medicare PIN